56 year-old Caucasian female (referred to as “Ms. X” for HIPAA compliance) presented with the following CC: “I am here to have my teeth checked out. I know I need to have many things redone, and a few of my crowns are cracked.” HPI: Ms. X denied any symptomology at this time, but reported “occasionally having a little sensitivity, pain, and bleeding,” when she flosses and brushes.


Ms. X is an ASA II patient with systemic diseases that are controlled and tolerated by means of polypharmacy. Most significantly,
her kidney disease inflicts daily pain and stress, as she continuously experiences kidney stones. In addition to that, Ms. X was diagnosed with SLE in 2019, which at times can be “completely debilitating.” Approximately 30 years ago, she experienced a stroke that resulted in temporary left arm weakness, but later resolved and had no long-term effects on her dexterity.

Importantly, Ms. X stated that in her past dental treatments, she experienced a “severe shaky behavior,” in response to local anesthetics.
Because of this, all anesthesia administered will contain 0% epinephrine, and in the event that heme control is needed, ViscoStat will be used. Details regarding Ms. X’s PMH are referenced below.

  • Kidney Disease – Nephrolithiasis

    • Ms. X reports having 5/10 pain daily; continuous kidney stones
  • Autoimmune Disease – Lupus (SLE)

    • Painful joints and generalized fatigue; at times, extremely difficult to walk
  • Cerebrovascular Event – Stroke

    • 1987: Ms. X had a clot that resulted in a stroke; left arm weakness
  • Past Surgeries/Operations:

    • 1983 – appendectomy; 1986, 1987 – cesarian section births; 1989 (to present) – kidney stone removal; 1989, 1990 – ovarian cyst removal; 1993 – hysterectomy; 1995 – gallbladder removal; 2015 – gastric sleeve, Roux-en-Y
  • Medications – aspirin, Percocet*, buprenorphine, gabapentin*, tamsulosin, doxycycline, alprazolam*, amphetamine salts*, methotrexate, prednisone, hydroxychloroquine, modafinil*, baclofen, amoxicillin-CLAV, Fe supplements, folic acid, and multivitamin

*denotes xerostomia as a common side-effect


Ms. X presented at her initial visit with multiple missing teeth, retained root tips, and several prosthodontic restorations including both crown- and bridge-work. Moreover, one of her FDPs was fractured at the mesial abutment tooth—the pontic site was in a cantilever-type state—and her occlusion was unbalanced. The patient expressed the importance of esthetics, as was evidenced by anterior veneers on her maxillary incisors that have been present for approximately 15+ years. Ms. X’s overall dental hygiene was fair at best, as she presented with clinically identifiable xerostomia, plaque, gingivitis, and generalized attrition of her mandibular incisors. Ms. X divulged that it has been since late-2019 since her last dental visit, and that she is motivated for treatment. Details regarding Ms. X’s dental findings are referenced below.

  • Head and neck exam (including TMJ) – WNL; no significant findings
  • Oral cancer exam – WNL; no significant findings
  • Gingiva presented in a mild-to-moderately inflamed state

    • Note: generalized erythema; plaque accumulation; mild tenderness to palpation
  • Low saliva production; thick and stringy – medication-related xerostomia
  • Missing teeth #s: 1, 2, 4, 5, 14, 15, 16, 17, 18, 20, 29-32

    • Note: #5 – congenitally missing
    • Note: retained roots for teeth #s 6, 12, and 22
  • PFM bridge: #s 3-P4P-6, with #6 crown fractured off
  • Porcelain veneers: #s 7-10
  • #13 – occlusal amalgam
  • PFM bridge: #s 19-P20P-21

    • Note: #19 – previously root canal treated
  • #22 – PFM crown with post; the crown and post were completely removable from the root of the tooth
  • Generalized attrition of the mandibular incisors




As evidenced from the FMX above, Ms. X has a history of extensive dental work ranging from single-unit crowns, three-unit FDPs, veneers, and an amalgam restoration. In addition, Ms. X’s retained root tips and edentulous spaces reveal a combination of horizontal and vertical bone loss, providing greater insight on her plaque and caries index, as well as her periodontal health.

There are no hard tissue pathologies noted, however, there is marginal discrepancies with recurrent decay on the existing restorations. It should be noted that all teeth, unless endodontically treated or a retained root tip, are vital and show no signs of pulpal involvement or infection. Teeth with suspicious radiographic involvement of the PDL-, pulpal-, and/or periapical spaces were clinically assessed and determined to be WNL, and rather a potential result of traumatic occlusion, or remaining scare tissue. Details regarding Ms. X’s radiographic findings are referenced below.

  • Missing teeth: #s 1, 2, 4, 5, 14, 15, 16, 17, 18, 20, 29-32
  • Retained root tips: #s 6, 12, 22
  • PFM bridge: #s 3-P4P-6, with #6 crown fractured off
  • Porcelain veneers: #s 7-10, with evidence of opened margins
  • PFM bridge: #s 19-P20P-21
    • #19 – previously root canal treated; recurrent decay present
  • #22 – PFM crown with post


The maximum pocket depth (PD) for Ms. X at any one site was 3 mm, with moderate bleeding on probing (BOP) at selective sites. It is important to note that sites of retained root tips were exempt from the charting as the slightest pressure in these areas caused severe discomfort for the patient – nevertheless, these teeth had a hopeless prognosis and were scheduled for extraction the following week. In addition, Ms. X presented with minimal recession, mobility, and localized areas of inadequate (2 mm) keratinized tissue.

Based on the 2017 World Workshop on the Classification of Periodontal and Peri‐Implant Diseases and Conditions, Ms. X’s periodontal diagnosis is classified as Generalized Stage II, Grade B Periodontitis. Details regarding Ms. X’s periodontal diagnosis are referenced below.

Periodontitis… Rationale(s) for Diagnosis:
→ > 30% of the teeth present are involved
Stage II
→ Interdental clinical attachment loss (CAL) at site of greatest loss = 3 mm
→ Radiographic bone loss (RBL) in the coronal third (15% to 33%)
Grade B
→ Moderate rate of progression

  • Direct evidence of progression: < 2 mm of RBL and/or CAL over the last 5 years
  • Indirect evidence of progression: destruction commensurate with biofilm deposits; 0.25-1.0% bone loss/age

Caries Risk Assessment:

Upon completion of a comprehensive oral evaluation, Ms. X was deemed as high-risk for caries.

Currently, Ms. X admits to brushing her teeth 2x/day and living within a fluoridated water community. She presented with multiple restorations and clinically visible plaque biofilm, which most likely resulted from a combination of the high sugar content in her diet and frequent snacking between meals.

White spots were noted on some smooth surfaces, and radiographic confirmation of decay aided in the clinical caries diagnosis. Ms. X’s saliva was thick and stringy, and reported as “dry mouth,” as a result of her xerostomia-inducing medications. Wetting solutions (ie. Biotene) were recommended to combat dry mouth.

Periodontal Disease Risk Assessment:

Upon completion of a comprehensive periodontal evaluation, Ms. X was deemed as moderate-risk for periodontal disease.

Ms. X had a high plaque index and evidence of BOP during periodontal charting, which she also occasionally noticed when she brushed or flossed her teeth at home.

Importantly, Ms. X has never used tobacco or been a smoker.


The first initiative in Ms. X’s preventive treatment is to place her on 3 to 4-month re-care visits with updated radiographs every 6 to 18 months. As a means to maintain her dental health at home, oral hygiene education and proper technique (ie. modified-bass) were provided; recommendations included power brushing, flossing (as well as super floss for the patient’s fixed prostheses), and interproximal aids (ie. proxy brushes, floss holders for efficiency, WaterPik).

Ms. X’s 5-day diet analysis was implicated in her high caries rate, and recommendations based on nutritional counseling included decreasing the frequency of sugar exposure, increased water intake (instead of soda or juice) during and after meals, and less snacking between meals/snack choices that are non-sticky to avoid retention in pits and grooves.

In combination with the aforementioned prevention plans, I recommended fluoride therapy as derived from the ADA clinical practice guidelines. Modalities for fluoride treatment included a prescription for 1.1% stannous fluoride toothpaste (which is both antimicrobial and anticaries) and 5.0% sodium fluoride varnish Q3 months. Ms. X was also informed on the antimicrobial effects of xylitol gum or mints, and 0.12% chlorhexidine rinse (used BID for 1 week/month).

Lastly, I am a firm believer of motivational interviewing. I focus much of Ms. X’s and my dialogue on encouraging her to maintain a good health status—specifically—because systemic and dental health share a bidirectional, synergistic relationship.


Throughout Ms. X’s and my conversations, it became apparent that she is challenged by four social
determinants of health: economic stability, neighborhood and physical environment, community and social well￾being, and health care system coverage.

Economic Stability
Ms. X is disabled and unemployed, which significantly impacted her family’s and her finances. Because of this, Ms. X was challenged to prioritized her medical bills and medications, in addition to other necessary life expenses, over dental care. This also placed limitations on the dental care that Ms. X could afford, which included frequent (ie. Q6 months) re-care visits. Ms. X knows the importance of professional exams, but felt the need to only visit the dentist “if she had a problem,” because of the financial gain that “no problems,” would have on her income.

Neighborhood and Physical Environment
Ms. X commutes to and from her dental visits from a location across state lines, making transportation a challenge as it is not always available for appointments times. She is also impeded by the financial contribution for gasoline, which in the event of inclement weather conditions, becomes allocated toward shorter commutes to other priority visits as they are geographically closer. This creates a barrier for treatment, as there have been times where appointments needed to be rescheduled to a later date, delaying the timeline of her care.

Community and Social Well-being
Being disabled, and therefore unemployed, took immense enjoyment out of Ms. X’s life. Her ability to walk comfortably has been negatively impacted by not only the pain from her kidney disease, but also exacerbated changes in her overall range of motion due to lupus. This left Ms. X challenged with social integration and discrimination (ie. “people think differently of me”), as well as community engagement, which collectively play the role of a major stressor in her life.

Because walking was consistently and severely painful for extended periods of time, Ms. X developed a more sedentary lifestyle, and admitted it being “very boring from how she used to live.” This “boredom,” resulted in increased unhealthy food choices and snacking within Ms. X’s diet, which significantly contributes to her high caries risk.

Health Care System Coverage
Within moments of our first interaction, Ms. X admitted that her insurance coverage will control much of what she can do as far as comprehensive treatment planning at this time. She divulged the fact that her family will be contributing to the cost of her dental needs as a result of this, further perpetuating the aforementioned social determinants.



  • Missing teeth
  • Caries of dentin
  • Caries risk high
  • Extrinsic discoloration
  • Nonrestorable carious tooth

(approximately 75% covered by insurance)

  • Prophylaxis cleaning + fluoride varnish
  • Caries excavation (followed by core buildup, if needed): #s 3, 6, 7, 8, 9, 10, 11, 13, 19, 21
  • Incisal-facial composite bonding: #s 23-26
  • Phase I re-evaluation

(0% covered by insurance)

  • PFZ FDP: #s 3-P4P-P6P-7-8-9; #s 11-P12P-13
  • PFZ crown: #10
  • PFM FDP: #s 19-P20P-21
  • Cast metal PRDP: mandibular arch

    • Replacing teeth: #s 22, 29, 30

Ms. X’s treatment begins with the goal of arresting and eliminating the progression of caries and maintaining dental health and hygiene (Phase I). After completion of Phase I, a re-evaluation will be done to assess previous work and check for new lesions. If new lesions arise, Phase I will continue until there is total rehabilitation of both the teeth and periodontium, whereby following that, Ms. X will begin Phase II.

Phase II treatment includes the replacement of current FDPs with newer, modified FDPs that are better suited for Ms. X’s dental needs. In addition, Ms. X agreed to a removable appliance for the replacement of her missing mandibular teeth. Composite bonding of the mandibular anterior incisors, albeit Phase I treatment, will take place at the end of Phase II. The reason for this delay is to provide the most accurate shade matching to the maxillary restorations, in addition to the absence of a bacterial-caries etiology related to these teeth (this treatment is completely esthetic in etiology).

* In order to provide treatment that fell within Ms. X’s budget of $11,000.00, consideration was taken for restorations on teeth #s 23-26. She initially wanted porcelain veneers, but after cost comparison with other treatment options, I recommended anterior composite bonding as this will still adequately match the shade of the new fixed restorations planned on her maxillary arch. Ms. X was pleased by this option, and agreed to follow through with it.

* Ms. X decided to have all remaining root tips extracted at a third-party oral surgeon not affiliated with my treatment – she was eager to have them extracted as soon as possible. At the time of treatment plan signing, tooth #6 was already extracted, and the remaining root tips were scheduled for extraction within that week.


Throughout Ms. X’s Phase I treatment, it was clear that the preventive measures she is currently utilizing are having a positive impact on her dental health. She admitted that her “teeth were less sensitive,” and that her “gums felt better,” one month after fluoride varnish treatment and staying compliant with a prescription strength stannous fluoride toothpaste at home.

In addition to that, during Ms. X’s hygiene visit, she was educated on the modified-bass brushing technique, and how the angle of the brush on the tooth allows for effective cleaning of gingiva as well. After incorporating this into her daily routine, and flossing properly more often, a marked decrease in bleeding while at home was observed by Ms. X, in addition to clinically less inflammation and BOP.

Overall, as Ms. X learned about the importance of diet in her caries and periodontal disease risk, she transitioned into healthier styles of living. As a result, Ms. X continues to show a healthier plaque index, and progression towards complete prevention is evident.

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